Claim Form - Health Insurance
Claim Form - Health Insurance Claim Form - Health Insurance
Attending Medical Practitioner's Statement To be answered by attending Medical Practitioner in complete. (To be filled in case discharge summary does not contain the following information) 1. Name of the Insured (in respect of whom the treatment is given) 2. Age 3. Address of the Insured Plot No./Door No. Building Name Road/Street/Sector Area Taluka/Village/District/City Pin Code State Country Telephone Mobile E-mail 4. Nature of the disease suffered by Insured 5. What treatment was given/operations performed, if any? 6. When did the first symptom appear? d d m m y y y y 7. Whether the present ailment is pre-existing or caused by any pre-existing ailment? If Yes, please specify For accident case: 8. Are the injuries traceable to any pre-existing ailment/infirmities? 9. Was he/she under the influence of intoxicants or drugs at the time of accident? 10. Any medico legal case filed? 11. Have you provided medical treatment to the Insured previous to this treatment? If YES, specify time since when you have been attending him/her? 12. If you have treated him/her for any previous illness or injury, please give details Signature of the Medical Practitioner Date: Name Dr. Regn. No. Address of the Doctor Plot No./Door No. Building Name Road/Street/Sector Area Taluka/Village/District/City Pin Code State Country Telephone Mobile E-mail Fax Version 1.3, May 2008
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Attending Medical Practitioner's Statement<br />
To be answered by attending Medical Practitioner in complete.<br />
(To be filled in case discharge summary does not contain the following information)<br />
1. Name of the Insured (in respect of whom the treatment is given)<br />
2. Age<br />
3. Address of the Insured<br />
Plot No./Door No.<br />
Building Name<br />
Road/Street/Sector<br />
Area<br />
Taluka/Village/District/City<br />
Pin Code<br />
State Country<br />
Telephone Mobile<br />
E-mail<br />
4. Nature of the disease suffered by Insured<br />
5. What treatment was given/operations performed, if any?<br />
6. When did the first symptom appear?<br />
d d m m y y y y<br />
7. Whether the present ailment is pre-existing or caused by any pre-existing ailment? If Yes, please specify<br />
For accident case:<br />
8. Are the injuries traceable to any pre-existing ailment/infirmities?<br />
9. Was he/she under the influence of intoxicants or drugs at the time of accident?<br />
10. Any medico legal case filed?<br />
11. Have you provided medical treatment to the Insured previous to this treatment? If YES, specify time since when you have been attending him/her?<br />
12. If you have treated him/her for any previous illness or injury, please give details<br />
Signature of the Medical Practitioner<br />
Date:<br />
Name<br />
Dr.<br />
Regn. No.<br />
Address of the Doctor<br />
Plot No./Door No.<br />
Building Name<br />
Road/Street/Sector<br />
Area<br />
Taluka/Village/District/City<br />
Pin Code<br />
State Country<br />
Telephone Mobile<br />
E-mail Fax<br />
Version 1.3, May 2008
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